Getting What We Pay For: How Do Risk‐Based Payments to Medicare Advantage Plans Compare with Alternative Measures of Beneficiary Health Risk?

Jacobs, Paul; Kronick, Richard

doi:10.1111/1475-6773.12977

Cited by 15 publications

(6 citation statements)

References 14 publications

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“…Our independent measure of health risk is a prescription drug‐based risk score that measures the relative health risk of Medicare enrollees. The measure was constructed by decomposing how prospective Medicare claims for hospital and ambulatory services are related to the therapeutic classes associated with prescription drug utilization 9 …”

Section: Methodsmentioning

confidence: 99%

The effects of coding intensity in Medicare Advantage on plan benefits and finances

Jacobs

Kronick

2020

Health Services Research

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Objective To assess how beneficiary premiums, expected out‐of‐pocket costs, and plan finances in the Medicare Advantage (MA) market are related to coding intensity. Data Sources/Study Setting MA plan characteristics and administrative records from the Centers for Medicare and Medicaid Services (CMS) for the sample of beneficiaries enrolled in both MA and Part D between 2008 and 2015. Medicare claims and drug utilization data for Traditional Medicare (TM) beneficiaries were used to calibrate an independent measure of health risk. Study Design Coding intensity was measured by comparing the CMS risk score for each MA contract with a contract level risk score developed using prescription drug data. We conducted regressions of plan outcomes, estimating the relationship between outcomes and coding intensity. To develop prescription drug scores, we assigned therapeutic classes to beneficiaries based on their prescription drug utilization. We then regressed nondrug spending for TM beneficiaries in 2015 on demographic and therapeutic class identifiers for 2014 and used the coefficients to predict relative risk. Principal Findings We found that, for each $1 increase in potential revenue resulting from coding intensity, MA plan bid submissions declined by $0.10 to $0.19, and another $0.21 to $0.45 went toward reducing plans’ medical loss ratios, an indication of higher profitability. We found only a small impact on beneficiary's projected out‐of‐pocket costs in a plan, which serves as a measure of the generosity of plan benefits, and a $0.11 to $0.16 reduction in premiums. As expected, coding intensity's effect on bids was substantially larger in counties with higher levels of MA competition than in less competitive counties. Conclusions While coding intensity increases taxpayers’ costs of the MA program, enrollees and plans both benefit but with larger gains for plans. The adoption of policies to more completely adjust for coding intensity would likely affect both beneficiaries and plan profits.

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Section: Methodsmentioning

confidence: 99%

The effects of coding intensity in Medicare Advantage on plan benefits and finances

Jacobs

Kronick

2020

Health Services Research

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“…Second, diagnosis upcoding in the Medicare Advantage program can make Medicare Advantage beneficiaries appear sicker than they are [31][32][33] ; the use of patient-reported health data in this study should have minimized this bias, but the populations still may have differed in unobservable ways.…”

Section: Limitationsmentioning

confidence: 99%

Association of Race and Ethnicity and Medicare Program Type With Ambulatory Care Access and Quality Measures

Johnston

Hammond

Meyers

et al. 2021

JAMA

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IMPORTANCEThere are racial inequities in health care access and quality in the United States. It is unknown whether such differences for racial and ethnic minority beneficiaries differ between Medicare Advantage and traditional Medicare or whether access and quality are better for minority beneficiaries in 1 of the 2 programs. OBJECTIVE To compare differences in rates of enrollment, ambulatory care access, and ambulatory care quality by race and ethnicity in Medicare Advantage vs traditional Medicare. DESIGN, SETTING, AND PARTICIPANTS Exploratory observational cohort study of a nationally representative sample of 45 833 person-years (26 887 persons) in the Medicare Current Beneficiary Survey from 2015 to 2018, comparing differences in program enrollment and measures of access and quality by race and ethnicity. EXPOSURES Minority race and ethnicity (Black, Hispanic, Native American, or Asian/Pacific Islander) vs White or multiracial; Medicare Advantage vs traditional Medicare enrollment. MAIN OUTCOMES AND MEASURESSix patient-reported measures of ambulatory care access (whether a beneficiary had a usual source of care in the past year, had a primary care clinician usual source of care, or had a specialist visit) and quality (influenza vaccination, pneumonia vaccination, and colon cancer screening). RESULTSThe final sample included 6023 persons (mean age, 68.9 [SD, 12.6] years; 57.3% women) from minority groups and 20 864 persons (mean age, 71.9 [SD, 10.8] years; 54.9% women) from White or multiracial groups, who accounted for 9816 and 36 017 person-years, respectively. Comparing Medicare Advantage vs traditional Medicare among minority beneficiaries, those in Medicare Advantage had significantly better rates of access to a primary care clinician usual source of care (79.1% vs 72.5%; adjusted marginal difference, 4.0%; 95% CI, 1.0%-6.9%), influenza vaccinations (67.3% vs 63.0%; adjusted marginal difference, 5.2%; 95% CI, 1.9%-8.5%), pneumonia vaccinations (70.7% vs 64.6%; adjusted marginal difference, 6.1%; 95% CI, 2.7%-9.4%), and colon cancer screenings (69.4% vs 61.1%; adjusted marginal difference, 7.1%; 95% CI, 3.8%-10.3%). Comparing minority vs White or multiracial beneficiaries across both programs, minority beneficiaries had significantly lower rates of access to a primary care clinician usual source of care (adjusted marginal difference, 4.7%; 95% CI, 2.5%-6.8%), specialist visits (adjusted marginal difference, 10.8%; 95% CI, 8.3%-13.3%), influenza vaccinations (adjusted marginal difference, 4.3%; 95% CI, 1.2%-7.4%), and pneumonia vaccinations (adjusted marginal difference, 6.4%; 95% CI, 3.9%-9.0%). The interaction of race and ethnicity with insurance type was not statistically significant for any of the 6 outcome measures. CONCLUSIONS AND RELEVANCEIn this exploratory study of Medicare beneficiaries in 2015-2018, enrollment in Medicare Advantage vs traditional Medicare was significantly associated with better outcomes for access and quality among minority beneficiaries; however, minority beneficiaries were si...

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“…Risk adjustment takes account of a member's conditions, as long as they are recorded in claims. MA plans are likely to record a more complete range of diagnosis codes than FFS Medicare (See for example [1][2][3][4][5][8][9][10][11][12]).…”

Section: Estimation Of Under-diagnosis and Under-reporting Of Chronic...mentioning

confidence: 99%

Estimating Under-diagnosis of Patients in Chronically-ill Populations

Huynh

Duncan

Stocking

2022

Preprint

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Diagnosis coding in administrative data is known to be inconsistent and incomplete, introducing inaccurate assessment of patients' health outcomes. The under-diagnosis of members with a target chronic condition reduces the correlation of that chronic condition with associated events. Yet, only a few studies have evaluated the extent of under-reporting of chronic conditions in administrative data. In this study, we developed a novel framework to identify latent members, or those who have not yet been identified with a target chronic condition through claims-based diagnosis but are likely to have some degree of the condition. We applied our innovative approach to estimate the prevalence of a chronic-related event, based on the population of observed and latent members. We provided a detailed illustration that treats incontinence as our target chronic condition while examining four types of incontinence-related events: urinary-tract infections (UTIs), slips and falls, dermatitis, and behavioral disruptions. All analysis relied on the 5% Medicare sample for a continuously enrolled cohort between 2014-2018. Using our novel approach, we were able to increase our identification of incontinence from the 11.2% diagnosed in 2018 to an estimated prevalence in 2018 of 34.7% among fee-for-service Medicare beneficiaries over the age of 65. Similarly, our estimation of UTIs associated with those with incontinence increased from 38% to 68%, from 20% to 41% for IAD, 22% to 54% for slips and falls, and from 26% to 57% for behavior disruptions.

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Getting What We Pay For: How Do Risk‐Based Payments to Medicare Advantage Plans Compare with Alternative Measures of Beneficiary Health Risk?

Abstract: Our results add to a growing body of evidence suggesting MA receives favorable, or, at worst, neutral selection. If MA beneficiaries are no healthier and no sicker than similar beneficiaries in TM, then payments to MA plans exceed what is warranted based on their health status.

Cited by 15 publications

References 14 publications

The effects of coding intensity in Medicare Advantage on plan benefits and finances

The effects of coding intensity in Medicare Advantage on plan benefits and finances

Association of Race and Ethnicity and Medicare Program Type With Ambulatory Care Access and Quality Measures

Estimating Under-diagnosis of Patients in Chronically-ill Populations

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